Ebook CBT for depression in children and adolescents: Part 2

Part 2 book “CBT for depression in children and adolescents” has contents: Cognitive restructuring and identifying unhelpful thoughts, problem solving, identifying skills for maintaining wellness and building the wellness plan, practice and application of core skills, relapse prevention plan and wellness plan,… and other contents.

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use This Core skill for

• All youth to teach the core skill of cognitive restructuring and identifying unhelpful thoughts

session objectives

• Introduce unhelpful thoughts and tie them to self- beliefs

• Help the youth to identify his or her own unhelpful thoughts and to come up with helpful thoughts

• Introduce the idea of self- beliefs (i.e., core beliefs) to the youth Begin to

conceptualize the youth’s core belief

• Describe the youth’s attributional style for positive and negative events

• Continue to identify unhelpful self- statements to target

session Checklist

1. Provide the parents with a handout on today’s topic while they wait

2. Set the agenda; elicit the youth’s agenda; evidence check (for or against self- belief)

3. Review self- reports (looking for possible residual symptoms)

4. Review the previous session (Did It Stick?, elicit feedback and summary, discuss results of homework/practice, discuss any adherence obstacles)

5. Teach cognitive restructuring and unhelpful thoughts and self- beliefs

Chapter 7

Session 3

Cognitive restructuring and identifying unhelpful Thoughts

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6. Perform homework/adherence check.

7. Elicit feedback and Make It Stick

In this session, the first 45 minutes of treatment will be spent with the youth in

an individual session, followed by a 45-minute conjoint session with the youth and parents

inTroDuCTion

After going through items 1–4 of the Session Checklist, begin this part of the session:

“It is easy to notice your feelings because that is probably what you are most aware of It is key to recognize that there is a thought behind this feeling For example, if you get a lower-than- normal grade back on a test, you may think, ‘I am stupid I will never pass.’ Then this makes you feel bad about yourself, and this could make you feel like it is not worth trying anymore The thought affects the feeling Or, if you are at school and someone walks

by and doesn’t say ‘hi’ to you, you may think ‘She doesn’t like me.’ But what

if she is running late for class, or she didn’t see you? The thought affects how you feel about yourself, but this thought may or may not be accurate.”

raTionale

This skill will be needed by all youth who have dealt with depression Actually, this skill would be useful for anyone who has ever had problems with “negative or unhelpful thinking” or has experienced cognitive distortions Recognizing how one thinks and learning to identify the common errors in thinking will help to adjust these thoughts and to replace them with more accurate thoughts

This skill helps to set the foundation for preventing relapse In addition, this treatment focuses on self- beliefs, or core beliefs of the youth By recognizing evi-dence for and against these core beliefs, the youth will hopefully be able to better manage his or her thinking and control his or her mood

TeaCh Define unhelpful Thoughts or negative/unhelpful self‑Talk

TherapisT Tip: This section contains many suggestions for how to

communi-cate this skill to youths We suggest some possible language to use with youth

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to introduce this idea Use anything needed to get the point across, but don’t try to use it all Use your best judgment of what will work best with your youth If the youth “gets it,” move on to the end of the section.

Thoughts and Mood

“When you are depressed, you feel bad, and in this treatment we focus on two factors that help maintain negative mood: thoughts and behaviors In this session we focus on thinking patterns Noticing the way you think is important to managing your mood and maintaining wellness When you have thoughts such as, ‘I did a great job with that,’ do you see how that would make you feel better? When one is depressed, sometimes one learns

to think negatively and practices this more We need to evaluate your ing patterns to see if some adjustment is needed to further improve your mood to prevent relapse.

think-“At times, there are some situations we can’t change, such as parents’ arguing But you can change the way you think about it and how you cope with the situation (i.e., behavioral coping skills).

“Today we are going to talk about thoughts Last week we discussed mood monitoring and ways to change your mood with behaviors Today

we are going to talk more about ways to change your mood by changing your thinking Remember, your mood is affected by your thoughts, feelings, and behaviors By working on changing your thoughts, we are also working on how to change your feelings, as thoughts can cause feelings.”The Role of Thoughts in Relapse Prevention

“You feel better now, but there may be some leftovers of the old thinking from when you were depressed This leftover thinking may be keeping you from getting completely well Today we are going to look at different ways that people think while they are depressed Then, if it is okay with you, we are going to look at your thoughts and see if any of these ways of thinking have become your style of thinking We are going to do a ‘check’ and see if any of these apply to you, then working on finding helpful ways of thinking, to prevent relapse in the future.”

The language that follows may be helpful with youth who may need more ples to understand the connection between thought and mood

exam-“Even though you are feeling better, you may not realize that you are thinking that way because it becomes automatic For example, when you first learned to ride your bike (or drive a car, play basketball, play

84 CBT FOR DEPRESSION IN CHILDREN AND ADOLESCENTS

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an instrument), you had to think about every move that you made You focused on each detail of every sensation, such as movement, balance, and feeling Then, after a while, you could do it without thinking—it became automatic That is how thoughts are When you were first depressed, you may have started to practice negative/unhelpful thinking With time, that probably became the way that you thought most of the time It may still

be how you think—an automatic way of thinking—and this could cause you to feel down again We need to relearn how to think—maybe give you practice thinking in a different, more realistic way With practice, this will become your automatic way of thinking.”

Changing Your Thoughts Is Possible

“Have you ever ‘changed your mind’ about something? How does the change happen? Did you question your old thought or get more information about something?”

• Introduce Handout 7.2, Risky Unhelpful Thoughts, and have the youth check those that apply to him or her

suggesTeD hanDouTs

9

9Downward Spiral (Handout 7.1)

9

9Risky Unhelpful Thoughts (Handout 7.2)

strategies to generate helpful Thoughts: Thought Check

• Check to see if the thought is helpful Check to see if the thought causes

prob-lems in mood (results in negative mood) “When you experience a negative mood shift, that should signal for you to do a thought check.”

• Challenge the thought: Connect this to the triangle “How does this thought

make you feel? What behavior does this thought lead to? Is this thought ting in the way of anything you want to do?”

{ Plan of action: “When you have this thought, is there something you could

do to change the situation or solve the problem?”

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• Change the unhelpful thought to a helpful thought.

9

{ Components of a helpful thought: realistic, makes you feel better, not extreme, not emotionally charged, not blaming

TherapisT Tip: Beware of the “thinking trap”—“If I feel stupid, I must be

stupid.” Remind the youth that Handout 7.3, Thought Check, is appropriate

in this case The therapist might consider using Handout 7.4, My Self- Belief,

to work on unhelpful beliefs The youth might indicate a belief about him- or herself that is particularly unhelpful, such as “No one likes me.” The thera-pist can indicate, using the circle as a pie chart, how much or what percent

of all youth believes the particular belief to be true For example, if it is 90%

true, then the therapist can say, “What would have to happen to get it to 80%?” The therapist helps the child to find ways to reduce the belief—such

as “I could go to the movie with a friend and I would believe it less.” The therapist can illustrate this activity as a piece of the pie chart that reduces the 90% piece to an 80% piece This activity can continue until the pie has several more “helpful” components to reduce the percent belief

9

9Thought Check (Handout 7.3)

9

9My Self- Belief (Handout 7.4)

attributional style (Ways of explaining Things)

Attributional style can be twisted or skewed when one is depressed, and then people can get stuck in a pattern—for example, blaming yourself when things go wrong or not noticing or paying attention when things go well Contract to explore with the youth his or her attributional style for both good things and bad things that hap-pen Research has shown that depressed adolescents have difficulty taking credit for positive events (i.e., depressed youth fail to make internal- stable- global attributions for positive events; Craighead & Curry, 1990) It is important for youths to “take credit” for good things that happen to them

“We find that when good things happen to people who are depressed, they say it happened because of ‘luck’ or external situations (e.g., ‘I made a good grade because the test was easy.’) It is important for us to watch for this We need to make sure you give yourself credit for the things that you

do well.

“I would like to make a deal with you that during the treatment, I can point out when I notice that you are not taking credit for the good things that happen to you that you have had a part in For example, if you study

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really hard and do well on a test, then tell me the test was ‘easy,’ I am going

to remind you that you studied hard, and that is why you did well.

“Giving yourself credit for the things that you do well will help you

to build positive self- beliefs, and these positive self- beliefs will protect you from relapse.”

self‑Beliefs and Building a positive self‑schema

“We’ve been talking about how your view of yourself influences your thoughts and mood We want to build a new idea of self that incorporates your strengths.”

People have different ways of viewing themselves

“For example, I am a therapist, a mother/father, a wife/husband, a ter/son, and many other things.”

daugh-In addition, people have ways of thinking about themselves

“For example, I am smart, or funny, or serious, or likable.”

These ways of thinking about yourself are called self- beliefs These beliefs can

be positive or negative (e.g., “I am smart” vs “I am stupid”) Most people never really think about why they believe certain things about themselves, and that is too bad because these self- beliefs affect our thoughts, mood, and actions!

“For example, I think that I am stupid, so I don’t raise my hand in class, even when I think I know the answer What would happen if I believe that

I am not stupid, or even believe that I am smart? How might my actions change? What would my mood and thoughts probably be like if I believe I

am smart and try to answer questions in class?”

Discuss with the youth that a main goal of this treatment is to think about these self- beliefs and to try to understand any evidence that we have for these beliefs (good

or bad) and against these beliefs (good or bad) Show the youth Handout 7.4, My Self- Belief, to better explain this concept

“The ways that people view themselves can impact what they do For ple, if a person sees himself/herself as likable and fun to be around, he or she is likely to interact with other people Self- beliefs (ideas or beliefs about myself that contribute to my mood, other thoughts, and behavior), both positive and negative self- beliefs, affect how we think, act, and feel Let’s

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exam-use this pie chart handout to think about ‘how much’ of you believes your most common self- beliefs.

“We just talked about a couple of beliefs you have about yourself For example, ‘I’m funny,’ ‘I’m stupid,’ and ‘No one likes me’ [use actual examples from the youth, in his or her words] What ‘percent’ of you believes each

of these self- beliefs? Each of these beliefs is associated with different moods.

“When you say ‘I’m funny,’ your mood is much better How can we increase the helpful self- beliefs and decrease the unhelpful self- beliefs? Both behaviors and helpful thoughts can change self- beliefs.

“If you want to decrease the ‘stupid belief,’ you can spend more time preparing for tests In addition, you cannot minimize accomplishments (give yourself credit) Use the thought check method to address any fre- quent unhelpful thoughts about being stupid.”

Common negative self beliefs include:

“I am unlovable.”

“I am unworthy.”

“I am not good enough I don’t measure up.”

Use guided discovery to continue to uncover the youth’s self- belief (e.g., “I noticed you said Is that the way you see yourself?”).

“Notice the good things you do Which ones fit for you?”

Introduce the idea of monitoring helpful self- thoughts (or positive self- beliefs) and how these impact mood

Apply the thought check model to the youth’s negative self- beliefs, if possible

suggesTeD aCTiviTY: flower pot Metaphor

It may be helpful to guide the youth in understanding this concept by using the phor of a flower pot or gardening If you fill the flower pot with rocks and sandy soil, then your plant will probably not be healthy and will have trouble growing to its full size However, if you take time to tend the soil, add fertilizer, and pull out the weeds, you will find that the plant will thrive and reach its full potential!

meta-Negative self- beliefs are like having sandy soil; no plant would grow well in this environment—think of the beach! There are not many plants on the shore!

Unhelpful thoughts are like the rocks in this sand, which inhibit the plant growth and mess up the roots

Positive self- beliefs are the good soil, full of nutrients and life Making positive butions for events or “taking credit” for what you do is like adding fertilizer, and it makes your plant grow even better!

attri-88 CBT FOR DEPRESSION IN CHILDREN AND ADOLESCENTS

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In this treatment, we would like to help weed the pot of the “bad stuff” (negative/unhelpful self- beliefs and unhelpful thoughts) and refill the pot with the good soil (posi-tive/helpful self- beliefs) and fertilizer (positive attributes).

TherapisT Tip: Continuously assess for the youth’s self- beliefs and

attribu-tions for events This is key in helping the youth to change how he or she thinks about the self!

praCTiCe in session

• Consider using Handout 7.2, Risky Unhelpful Thoughts, to help the youth

practice finding the unhelpful thoughts.

• Role-play with the youth using yourself as an example Give the youth a tive thought that you have had (e.g., “I was late to work this morning, so I am going to get fired.”), and have him or her apply the thought check model Try

nega-to connect negative thoughts with negative self- belief, if possible

applY To TiMeline

“How would these strategies have helped you in the past?”

“How can they help you this week?”

“How can you use them in the future?”

If the youth has not already been able practice noticing unhelpful thoughts, help apply “thought check” to a specific thought that he or she has had over the past week Go through the whole process with the youth’s thought Have the youth identify the thought behind the feeling and do a thought check

• Past: “What are some thoughts that you had when depressed? Or, if you can’t remember, what do you think you were thinking back then, based on your symptoms? Knowing what you know now, could you talk back to these thoughts and change them?”

• Present: “Are any of these old thoughts still around?”

• Future: “Anticipate some situations for this week, and let’s think of some positive self- statements that could be used in that situation (e.g., if third period at school is bad every single day, then anticipate some positive self- statements to use during this time).”

• “Make and keep a list of positive thoughts or self- statements that might work for you.”

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to it The youth can practice with these like flashcards.

4 Come up with some positive self- statements that could be used during the week Have the youth anticipate situations in the upcoming week where these positive statements could be used Incorporate positive self- statements into self- monitoring and the homework assignment

5 Have the youth pay attention to the good things that happen in the upcoming week Have the youth practice “taking credit” for these things

MaKe iT sTiCK

Have the youth share what he or she learned in the session and list these items on a Make It Stick Post-it note You can add any additional points to this list The youth may also give feedback about what was the most helpful from the session Share what you learned about the youth during this session (i.e., reinforce the youth’s strengths)

In addition, you can create a postcard to send the youth during the week with the main points from the session This should help the youth remember to practice what was learned in- session

Suggested items for the Make It Stick include:

• Positive self- statements for the week ahead

• Common unhelpful thoughts and helpful thoughts

• Steps to thought check

• Give self credit for events

• Apply skill to a specific, personal example

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TransiTioning To The faMilY session

Discuss the family session with the youth prior to inviting parents into the session.First, review what will be discussed in the parent session

• Work collaboratively with the youth to set a workable agenda for the parent session

• Determine what issues would be helpful to discuss further

• Determine any issues that the youth does not want to discuss during the ent session

par-• Get the youth’s “buy-in” and collaborate with the youth on how this concept may relate to his or her family and be helpful in the youth’s treatment

• Have the youth think about how this new family skill might be applied to the timeline Consider what the family can do to help support the youth in preventing relapse

iDeas for The TherapisT

• Use vignettes.

• Instead of common distortions, simplify

into “red flag” words.

• Which ones might he or she “catch” this

week?

• Ask permission to use Mom or Dad or

a significant other to help the youth to

catch the red flag words; can they “catch”

them as a family?

• Handout 6.9, Lift Your Mood.

• Use real-life examples.

• Where are the unhelpful thoughts on this youth’s timeline?

• How can this skill be used to prevent relapse?

• Have the youth consider how the belief gets in the way.

• State the thought and then rate the

feeling in the session.

• Have the youth teach the parent about

unhelpful thoughts.

• Use Handout 6.3, Feeling Faces.

• Play Nerf football/basketball, having the

youth describe thoughts after missing

and making shots.

• Use Handout 7.2, Risky Unhelpful Thoughts; which ones are familiar?

• What situations does the youth anticipate this week where he or she might catch the thought?

• Thought journaling.

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family session: Cognitive restructuring

agenDa

Collaborate with the family to set an agenda for the family session

• Check in with the family on any previously assigned homework

• Elicit feedback on the program and the past week Continue to gather mation on past factors associated with the youth’s depression (particularly family factors) and their input on current residual symptoms and anticipated future obstacles (add these to the timeline) Continue to get parent input on treatment goals for the program

infor-• Elicit any questions parents may have after reviewing the parent handout An optional agenda item is to have the youth teach the cognitive restructuring and unhelpful thoughts to the parents

• Remember to prioritize the agenda items collaboratively

TeaCh anD praCTiCe introduce Cognitive restructuring and unhelpful Thoughts

• Remind parent and youth of the cognitive model of depression and bring out the triangle

“In this program, youth are taught to identify thoughts and tions and challenge and change unhelpful thinking This same process can be very helpful to parents.”

attribu-• Introduce the idea that negative/unhelpful thoughts run in families

“Do you have any negative/unhelpful thoughts about yourself?”

• Identify negative attributions that the parent has regarding him- or herself, the world, or the future Be alert to opportunities to teach developmental norms for youth Many adolescents exhibit thinking that is self- focused This

is normal for this age group and is not necessarily pathological

• Parents often have unhelpful thoughts regarding their depressed adolescent These thoughts can increase parent–child conflict and solidify the negative automatic thoughts of the adolescent

• Use Handout 7.2, Risky Unhelpful Thoughts, as a teaching tool to show ples of automatic thoughts Have the family brainstorm any negative/unhelpful thoughts about their family or about each other, such as “Dad is never home”

exam-or “Mom is always on the phone” exam-or “My brother is lazy.” Have the family practice the thought check method, taught earlier in- session to the youth

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suMMarY anD hoMeWorK/praCTiCe

Summarize the family session

• Assess the family’s understanding of cognitive restructuring and unhelpful thoughts

• Elicit feedback about the session

“How is this relevant to your family’s situation?”

“How can I, as the therapist, be helpful?”

• Have the family summarize the session

Collaborate to develop a family homework assignment Homework ideas include the following:

• Contract with the family to have members point out to each other when they hear a negative or “unhealthy” attribution or statement How can this be pointed out, without seeming critical? Have the family report back on some

of these thoughts in a later session For families with high EE, this may not

be a good idea

• Have each member of the family keep a mood monitor journal where thoughts are recorded These do not have to be shared with each other but would serve

as an exercise for individual reflection

• As an experiment, have the family designate a “daily affirmation time.” tice making affirming statements about each member of the family Then assess the result of this on the family environment and the mood of fam-ily members Designate a time of day when family members regularly get together (such as dinnertime)

Prac-DiD iT sTiCK? (revieW quesTions froM The session)

1 What are automatic unhelpful thoughts? What positive self- statements do you need to increase with practice?

2 Why should we “catch” them?

3 How are they important in relapse prevention?

4 Self- beliefs—What is my negative or positive self- belief? What can I do when

I notice thoughts that contribute to my negative self- belief?

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Case example: session 3

In Session 3, the therapist and Lily reviewed the behavioral coping practice that she did over the past week, noting that her mood did improve after she took the dog for

a walk or worked on her art projects She found it hard to do the activities on days that she was feeling sadder or was stressed about her school work The therapist and Lily discussed scheduling one coping activity a day and explored how to include parents in helping her to stick to this schedule

The therapist introduced unhelpful thoughts and their relationship to mood and behaviors and relapse prevention Lily was able to identify several recurring unhelp-ful thoughts (e.g., “I’m stupid,” “My parents love my sister more than they love me,” and “I will never have friends.”) Lily was able to understand the connection between these thoughts and negative mood In addition, she could link the thoughts

to her behavior and current situation (e.g., “I’m stupid” would lead to not even ing to study for a test; “My parents love my sister more, so I am not important and don’t matter” would lead to her staying in her room and sleeping; “I will never have friends” would lead to avoiding talking to people at school)

try-The therapist introduced strategies to generate helpful thoughts, using the thought check skill In the session, the therapist and Lily worked on the thought “I

am stupid.” This is a thought that Lily could tie to increased sadness and ness The therapist and Lily used the check, challenge, and change approach:

hopeless-• Check: The thought was unhelpful due to its resulting negative mood, as well

as a tendency to “give up” or not try in school

• Challenge: Several strategies were used to challenge the thought

Contradic-tory evidence was identified, including that Lily was a straight A student prior to her onset of depression In addition, she recently has been getting good grades in her English classes and has only one subject that is difficult for her Lily used the alternative thoughts strategy to generate helpful thoughts, including “I am able to do better work,” “I am good at many things,” and

“Lots of people struggle in math who are smart.”

• Change: Lily wrote down the alternative thoughts above on a coping card

She set the goal of practicing saying these thoughts to herself whenever she struggles in math or feels down about school In addition, she decided that she would spend more time after school on her homework These alternative thoughts were added to the timeline (see Figure 7.1) Once she identified this pattern of thinking, Lily was able to plan ahead for when to use the thought check skill

The therapist ended the session by planning for the family session with Lily and assigning a thought record for homework

94 CBT for Depression in ChilDren anD aDolesCenTs

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figure 7.2 Postcard reminder after Session 3.

The therapist asked, “What unhelpful thoughts might be useful to review with your parents?” They identified Lily’s tendency to compare herself to her twin and her belief that her parents valued her sister more than they did her In the family ses-sion, the therapist asked Lily to explain the connection between unhelpful thoughts and mood to her parents She discussed her belief that they loved her sister more than her Her parents and Lily used the thought check skill together to address Lily’s unhelpful thoughts about her role in the family The parents were able to point out how at times it seemed that Lily ignored the positive statements that they have made

to her In addition, the parents identified some unhelpful family beliefs, “Lily does not want to be around us,” which resulted in the parents not planning family activi-ties The parents were more aware of Lily’s feeling criticized, and they made a plan

of action They would try to be more aware of her unhelpful thinking and would provide more support In addition, the family planned two family activities for the week, and Lily agreed to participate The therapist sent a postcard over the next week (see Figure 7.2), which included a review of thought check and a reminder to practice using her helpful thoughts and to follow through with the family activities

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From CBT for Depression in Children and Adolescents: A Guide to Relapse Prevention by Betsy D Kennard, Jennifer L Hughes,

and Aleksandra A Foxwell Copyright © 2016 The Guilford Press Permission to photocopy this handout is granted to purchasers of this book for personal use or use with individual clients (see copyright page for details) Purchasers can download additional copies

of this handout (see the box at the end of the table of contents).

What’s the point of having to know about

American history (any subject)?

If my team loses, it will be my fault.

Adapted from TADS manual.

handout 7.2

riSky unhelpFul thoughtS

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99

thought CheCk

CHECK YOUR THOUGHT

CHALLENGE YOUR THOUGHT

CHANGE YOUR THOUGHT



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100

handout 7.4

My SelF-BelieF

Percent Belief:

Date:

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101

• All youth to help with problem solving

• A youth who has difficulty in coming up with solutions to everyday problems

• A youth who has trouble recognizing problems and thus solving them as such

• A youth who presents a problem or dilemma during agenda setting

• Learn to define a problem and/or to identify common problems

• Understand FLIP and how to use this approach when problem solving

• Apply FLIP to a specific, personal problem

5. Teach problem solving

6. How does this skill fit in on the timeline?

Session 4

problem solving

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7. Perform homework/adherence check.

Point out that in earlier sessions, the youth learned ways of coping with ations that cannot change (through use of behavioral coping skills and cognitive restructuring) Stress that this skill (problem solving) is useful when the situation can be changed

situ-raTionale

Problem solving is a useful skill in every aspect of life The best way to deal with

a lot of issues that upset you is to change them This may sound easy, but it takes practice to brainstorm all options and pinpoint the best one for the situation Refer

to common problems that the youth has brought up, such as social and family flict, academic problems, or problems with homework completion (see the Adher-ence Supplement in the Appendix for this problem as well) If the youth included a problem on the agenda, use this problem as an example

con-TeaCh Define “problem”

“What is a problem? Basically, a problem is a dilemma in which you have

to make a choice about something or any situation that causes you to be anxious, worried, or stressed out A problem can be a source of stress.”

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Have the youth list some of his or her own problems from the past or present or anticipated problems in the future.

“Now that we both have a better understanding of what problems are, let’s talk about solving them! It is important to have a general strategy for problem solving.”

9

9FLIP the Problem (Handout 8.1)

9

9FLIP the Problem (Example) (Handout 8.2)

problem solving: flip

“When you encounter a problem, FLIP the problem to look at all sides.”

F: Figure out what the problem is and what you want to happen.

L: List all possible solutions.

I: Identify the best solution.

P: Plan what to do next.

F: Figure out what the problem is and what you want to happen.

“Sometimes when people are overwhelmed, it can seem like everything in life is part of the problem This often leads to more stress! In order to solve the problem, you need to figure out exactly what the problem is.”

L: List all possible solutions.

“Even adults often overlook this step in problem solving Most problems have many possible solutions The trick is to brainstorm all of these possibilities before choosing one It is really important to focus on all possibilities without judging the solutions at this point No potential solution is bad.”

I: Identify the best solution.

“Once you have listed all possible options, you can fill in the positive sequences (‘pluses’) and negative consequences (‘minuses’) of each one After looking at the positives and negatives of each option, it often is easy

con-to choose a solution—the one with the most ‘pluses’! If it is not obvious which solution is the best, then continue to brainstorm any ‘pluses’ or

‘minuses’ that you might have left off the list.”

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P: Plan what to do next.

“After choosing a solution, it is important to plan how to carry out this solution Once you have acted on this solution, evaluate how it worked and how you feel about the problem now If the problem still causes you stress, FLIP the problem again and come up with some new ideas.”

praCTiCe in session

Have the youth help you to apply FLIP to either (1) his or her own problem or (2) a problem of someone else There are some youth who have a hard time verbalizing one of their own problems In this event, it is fine to use a vignette or sample prob-lem in order to teach the steps in the skill

TherapisT Tip: List some solutions that are extreme or unlikely to emphasize

that, while brainstorming, you are just listing, not evaluating, the solutions That comes in the next step, Identify

applY To TiMeline

Have the youth anticipate a problem that is coming up in the week ahead Have the youth FLIP the problem to see all sides Help the youth to brainstorm specific details about the solution to this problem and to anticipate any “bumps in the road” that may come up while applying FLIP

hoMeWorK/praCTiCe

Collaborate with the youth to identify how he or she can use what was learned in this session over the next week Be specific!

Suggestions include:

1 Anticipate the problem in the week ahead, such as having trouble at school

or home Apply FLIP and report back on how it worked

2 Come up with some positive/helpful self- statements that could be used during the week Have the youth anticipate situations in the upcoming week when

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these positive statements could be used Incorporate positive self- statements into self- monitoring and homework assignments.

Contract with the youth to complete a Wellness Log over the following week if the youth is completing wellness at this point (see Figure 4.1 in Chapter 4)

suggesTeD hanDouT

9

9Wellness Log (Handout 8.3)

MaKe iT sTiCK

Have the youth share what he or she learned in the session and list these items on

a Make It Stick Post-it note The therapist can add any additional points to this list The youth may also give feedback about what was most helpful from the ses-sion Share what you learned about the youth during this session (i.e., reinforce the youth’s strengths)

In addition, the therapist can create a postcard to send the youth during the week, with the main points from the session This should help the youth remember

to practice what was learned in- session

Suggested items for the Make It Stick include:

• Definition of “problem”

• FLIP method steps

• Application of skill to a specific, personal example

iDeas for The TherapisT

• Have the youth apply FLIP to an example

problem.

• Bring in the family and have the youth

teach the skill to his or her parents.

• Have the youth apply FLIP to some of his

or her own common problems.

• Role-play in-session Contract to do FLIP

this week (may include parents in the

contract).

• How might this skill fit on the timeline— how might it have been used on a past problem? What about a current problem

or future problem?

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family Check‑in

DiD iT sTiCK? (revieW quesTions froM The session)

1 What is problem solving, and why is it important?

2 What are some common problems that people encounter?

3 Describe how to FLIP a problem to see all sides

Case exaMple: session 4

In Session 4, the therapist and Lily reviewed the thought record that Lily completed over the past week She was able to identify unhelpful thoughts related to school and

at home Of note, Lily used the check, challenge, and change strategies in order to change her unhelpful thoughts to more helpful/positive ones Lily also noted that she actually enjoyed the family activities, and she expressed interest in planning more activities in the upcoming week Lily reported an increase in mood rating (from 5 to 3) when she used cognitive restructuring at home and school

The therapist and Lily set the agenda for the session, and the therapist duced problem solving On the agenda, Lily reported that she wanted to address her difficulty in finding fun things to do with friends She explained that prior to being depressed, she was very socially active However, lately she has been avoiding hanging out with friends, preferring to stay home and watch TV in her room To tie the new skill to Lily’s agenda item, the therapist asked, “How would it be for you

intro-if we used the problem you put on the agenda today to practice FLIP, a strategy for making changes in your life?” Lily agreed, and the therapist and Lily collaboratively completed the FLIP handout as follows:

F: First, Lily was able to figure out that the problem was that she was spending

too much time alone In addition, she could state that she wanted to be with friends more often and have fun

L: Lily was able to list several possible solutions to address this problem She

listed activities that she used to like to do for fun as well as several friends she could approach easily At first, she wrote down some activities that she said she no longer liked to do The therapist reminded her that she could evaluate the options at a later step, but for now, she should focus on generating all ideas without judgment Having just learned the cognitive restructuring skill, Lily was asked by the therapist to consider what thoughts might be helpful

in this process Those thoughts were put on the list as well— including “I can

do this; I have had many friends before and I can again.”

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I: Lily was able to go through and evaluate each solution, using a plus sign for

solutions that might work and a minus sign for those that would be less mal or have a potential negative consequence (such as re- connecting with a friend that brings her mood down)

opti-P: She was able to “pick and plan” as the final step She decided to try to invite

a friend to meet her at the movies to see a new film based on their favorite book Lily role- played with the therapist how she would ask the friend to join her They also discussed what support she might need from her parents, such

as getting a ride to the movies She also identified some helpful thoughts, such as, “It will be fun to see her,” and “I used to love going to the movies with her,” to aid her in successfully using the plan

The parents were included at the end of the session to review the skill and Lily’s plan

to work on increasing her social activities Lily was able to explain the FLIP method for problem solving to her parents In addition, the problem- solving skill was dis-cussed as one that could be used by the family They discussed using the FLIP skill

at home as a tool to reduce conflict and negotiate solutions Lily and her parents discussed a fight that she and her sister had about how much time Lily’s sister spends getting ready in their shared bathroom in the mornings The family agreed to use the FLIP strategy as a family to address this issue and devise a plan

Homework was assigned to practice using FLIP in the next week both at school and at home

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108

IDENTIFY the best solution

PLAN when and where to use this strategy

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109

Flip the proBleM (exaMple)

IDENTIFY the best solution

PLAN when and where to use this strategy

• Study with a friend

• Ask the teacher for help

• Make a study schedule

• Get a tutor

• Change classrooms or teachers

• Read the chapter several times

Made a low grade on the test

• I would like to make a higher grade next time.

Make a study schedule

1 Create a weekly schedule and block off time to study

2 Begin the schedule a week before the test

3 Make flashcards and review during study time

4 Studying can be done on the kitchen table

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111

• All youth to introduce the wellness continuum and the six S’s of wellness

• Please note: When planning for this session, have the youth complete Handout 8.3, Wellness Log, in the preceding week

• Identify the wellness continuum

• Introduce the six S’s of wellness

• Help the youth to develop a Wellness Plan

5. Teach Wellness

Session 5

identifying skills for Maintaining Wellness

and Building the Wellness plan

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6. How does this skill fit in on the timeline?

7. Perform a homework/adherence check

raTionale

This is a time in the program when the focus is on maximizing outcomes and taining health To this end, the therapist will identify current skills and strategies that the youth is using to improve and maintain positive mood and identify skills that need to be added

main-When people are ill, all focus shifts to the illness and less attention is paid to overall wellness and health On the illness– wellness continuum, so far this treat-ment has focused on the illness side and on strategies targeted primarily at reducing depressive symptoms It is now time to focus on the other side of this continuum—those behaviors and practices that lead to an optimal quality of life

TeaCh/praCTiCe in session Wellness Continuum

The final goal of this treatment is to equip the youth with skills for wellness The youth needs to understand that this treatment does not just strive for the prevention

of relapse, but that the end result would be for him or her to “live life to the fullest.” Introduce the wellness continuum Explain the illness– wellness continuum in regard

to depression

TherapisT Tip: Define continuum as a range where wellness can fluctuate

over time You can be more well or less well; it is not a black and white cept

con-112 CBT FOR DEPRESSION IN CHILDREN AND ADOLESCENTS

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“What we have really focused on are skills to reduce depression and sive symptoms Now we want to add in skills and tools to increase the amount of time that you are not depressed—these are the positive behaviors and attitudes that keep you healthy and happy! These can be thought

depres-of as tools to help extend your periods depres-of wellness.

“Have you ever had an injury, like a sprained ankle? Remember that when you first hurt yourself, you had to stay off of that ankle, and you had

to sit out for awhile in sports Later, when the ankle had healed, you could begin to work on strengthening and conditioning your ankle, making it stronger and more flexible This should help prevent future injury.

“These wellness skills can be thought of as strengthening your life, helping you to fend off trauma, illness, and stress When you use these new skills and tools, you will be making yourself more flexible and strong as a person.”

The six s’s of Wellness

“Let’s look at your ‘Wellness Log’ together now What are your thoughts about wellness in your life? What would you like to focus on?”

Review Handout 8.3, Wellness Log, with the youth Go over each area, tifying and emphasizing areas that the youth already excels in Validate the youth’s strengths and emphasize skills that the youth is already using for wellness After you’ve done this, identify any areas of wellness that the youth is willing to work on

iden-In this way, you help the youth to achieve balance in wellness

This process needs to be collaborative and interactive

“In this program, there are six general areas of wellness.”

The six s’s

1 Self- acceptance (positive self- schema; explanatory style/optimism)

2 Social (social skills, social problem solving)

3 Success (autonomy/mastery)

4 Self-goals (purpose)

5 Spiritual (optimism, gratitude, altruism)

6 Soothing (relaxation) (Ryff & Singer, 1996)

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• Self- acceptance: Remind the youth of positive/helpful self- statements.

“Which helpful self- statements are you already using?”

“Are there some that you would like to increase or practice with more often?”

• Social: Social support is particularly important because it is what makes you

feel connected in this world, and connections to other people are what make

life fun! Consider using Handout 9.2, Who’s on Your Team, here.

• Success: Having a sense of mastery in some areas of life is important in taining wellness “Do we notice the good things that happen and our role

main-in them?” Be aware of attributions for positive events and the importance of

building the positive self- schema

• Self-Goals: Having goals gives people hope and a sense of purpose Discuss

with the youth the importance of having short-term goals and long-term goals Having something to look forward to is an important aspect of keep-ing up hope and maintaining wellness

• Spiritual: Self- awareness, including recognition of one’s values and beliefs

and living in conjunction with those values and beliefs, is a key part of ness It is also important to respect the views of others (tolerance) and to participate in activities that help others (altruism) in a way that will better connect you to the world around you Introduce optimism and a hopeful

well-view of the world Some people get hope from faith: “Do you have faith (in

a higher power? In your values? In yourself?)?” Revisit the explanatory or

attributional style as needed

• Soothing: Stress has detrimental effects on the mind and body Relaxation

is key to maintaining health It is important to use strategies that are self- soothing Use the relaxation training and sleep hygiene supplement in the Appendix as needed if this is an area of weakness for the youth Examples might include taking a bubble bath, listening to relaxing music, and eating a good meal

9Wellness Log (Handout 8.3)

114 CBT for Depression in ChilDren anD aDolesCenTs

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Development of the Wellness plan

Introduce Handout 9.4, The Plan, collaborating with the youth to complete this plan based on information gathered from Handout 8.3, Wellness Log The youth may choose to focus on one or two areas of wellness, rather than filling in several categories Stress that the goal of this activity is to “be the best me.”

2 Have the youth continue the Wellness Log for the next few weeks to track his

or her wellness progress

3 Come up with some positive self- statements that could be used during the week Have the youth anticipate situations in the upcoming week where these positive statements could be used Incorporate positive self statements into self- monitoring and homework assignment

5 Contract with the youth to thank someone who has helped him or her or has done something nice for him or her in the past

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MaKe iT sTiCK

Have the youth share what he or she learned in the session and list these items on a Make It Stick Post-it note You can add any additional points to this list The youth may also give feedback about what was the most helpful from the session Share what he or she learned about the youth during this session (i.e., reinforce the youth’s strengths)

In addition, you can create a postcard to send the youth during the week with the main points from the session This should help the youth remember to practice what was learned in- session

Suggested items for the Make It Stick include The Six S’s of Wellness (Handout 9.1)

TransiTioning To The faMilY session

Discuss the family session with the youth prior to inviting the parents into the sion

ses-First, review what will be discussed in the parent session

• Work collaboratively with the youth to set a workable agenda for the parent session

• Determine what issues would be helpful to discuss further

• Determine any issues that the youth does not want to discuss during the ent session

par-iDeas for The TherapisT

• Teach wellness to parents.

• Use real-life examples.

• Assign areas for practice • Explanatory style and optimism—help

youth identify how these are linked.

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• You will want to get the youth’s “buy-in” and collaborate with the youth on how this concept may relate to his or her family and be helpful in the youth’s treatment.

• Have the youth think about how this new family skill might be applied to the timeline Consider what the family can do to help support the youth in preventing relapse

agenDa

Collaborate with the family to set an agenda for the family session

• Check in with the family on any previously assigned homework

• Elicit feedback on the program and the past week Continue to gather mation on past factors associated with the youth’s depression (particularly family factors) and their input on current residual symptoms and anticipated future obstacles (add these to the timeline) Continue to get parent input on treatment goals for the program

infor-• Elicit any questions parents may have after reviewing the parent handout An optional agenda item is to have the youth teach the concept of wellness to the parents

• Discuss the treatment termination plan for the family Remind the family that three scheduled sessions remain, with optional booster sessions available after that

• Remember to prioritize the agenda items collaboratively

TeaCh anD praCTiCe introduce Wellness

“On the illness– wellness continuum, so far this treatment has focused on the illness side and strategies targeted primarily at reducing depressive symptoms It is now time to focus on the other side of this continuum—to those behaviors and practices that lead to an optimal quality of life.”

∗ Note: Activities in this family session may be used in the individual session as well.

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• Introduce the idea of wellness practices as a protective mechanism to prevent

a relapse of depression Introduce Handout 9.1, the Six S’s of Wellness

• Consider having the youth share his or her wellness plan with the family What can the family do to support your youth’s individual wellness?

• Collaborate with the family to assess the family level of wellness, and bly develop a family wellness plan, using Handout 9.1 What does the family already do that promotes wellness? What can the family add that will increase wellness? Does the family have enough activities in each of the “S” categories?

possi-Do any “S” categories need more? Examples of ways to assess each “S,” as well as suggestions for improving an “S” category, are included below

Self‑Acceptance

How does the family contribute to the youth’s self- acceptance? How are individual differences valued in the family? What is the view of the family as a whole? What are the family’s strengths?

Things to Try

• Reduce negative self- statements and increase positive attributions

• Develop a family motto or mission statement

• Have parents serve as coaches to recognize and help correct negative self- statements or negative family attributions

• Identify and affirm the individual strengths and unique qualities of each ily member Plan ways to acknowledge and celebrate these differences in the home

fam-• Brainstorm ways that parents can assist the youth in improving the youth’s own personal wellness in this area

Social

How does the family get social support? How can they help their youth have access

to more social support?

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How does the family succeed? What are you proud of as a family? (Examples include

“We keep our home clean,” “We take care of our extended family,” and “We are good neighbors”) Does the family notice the good things that happen and each member’s role in these good things?

Things to Try

• Develop a list of successes that your family has achieved

• Identify any activities that you would like the family to spend more time on

• Brainstorm ways that parents can assist the youth in improving the youth’s own personal wellness in this area

• Discuss the youth’s short-term goals and long-term goals with the family How can the family support these goals?

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• Consider using a white board or chalkboard, where family members can write statements of gratitude to other family members.

• Have the family practice the “thank a mentor” model, where each member writes an appreciation letter to a personal mentor

TV, consider trying other ways to relax, such as taking a walk together, doing

a puzzle, or reading together

suMMarY anD hoMeWorK/praCTiCe

Summarize the family session

• Assess the family’s understanding of wellness concepts and activities

• Elicit feedback about the session

“How is this relevant to your family’s situation?”

“How can I, as the therapist, be helpful?”

• Have the family summarize the session

Collaborate to develop a family homework assignment Homework ideas include:

• Identify the parts of wellness to work on for the week For example, does the family want to try to work on one “S” per week?

• Contract with the family to do some of the “Things to Try” items discussed previously

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DiD it Stick? (Review QueStionS fRom the SeSSion)

1 What is meant by “continuum of wellness”?

2 What are the six S’s?

3 How did you improve your overall wellness in the past few weeks?

caSe example: SeSSion 5

In Session 5, the therapist and Lily reviewed the FLIP practice activity from the past week Lily was able to ask a friend to a movie and reported that she had a great time She had rated her mood before and after the event, and noticed the connection between this social activity and positive mood Lily reported that her mood rating ranged from 1 to 3 over the past 2 weeks, which was improved from prior weeks Together, the therapist and Lily examined the thoughts and behaviors that were keeping her mood at this level She reported being more active and not staying in her room as much, eating dinner with her family at the kitchen table, and accepting her friend’s invitation to get frozen yogurt She also noted that she had been using the thought check skill to develop more helpful thoughts

The therapist presented the idea and importance of wellness and how being well

is connected with our behavior choices, as well as how we view ourselves, our world, and our future She also explained that wellness skills are helpful in preventing relapse of depression The six S’s of wellness— social activities, soothing activities, self- acceptance, self-goals, success activities, and spiritual activities—were intro-duced by the therapist Lily and the therapist reviewed the wellness activity log, noting Lily’s wellness strengths and activities she is already doing that might keep her well In addition, the therapist asked Lily for ideas about what she would like to increase or work on to improve her level of wellness Lily answered that she would like to focus on increasing social activities, soothing activities, and success activities

Social activities: Lily’s goal is to expand her circle of friends She was able to

identify two additional friends whom she would like to get to know better Ideas were generated for ways to connect with these friends as well as for ideas of fun things they might do together

Soothing activities: Lily had very few activities that she found to be relaxing,

although she admits that reading is something she finds calming The therapist asked

if she wanted to find out more about soothing activities The therapist introduced progressive muscle relaxation and deep breathing (see pp 173–174 in the Appen-dix for supplemental materials) Together they planned a few practice activities for the upcoming 2 weeks Lily agreed to practice either deep breathing or progressive muscle relaxation prior to bedtime, as this was a time of worry and stress for her

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